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Liver disorders

Intrahepatic cholestasis of pregnancyWhat is ICP?Intrahepatic cholestasis of pregnancy (ICP) is a pregnancy-related liver disorder in which there are abnormalities in the flow of bile (a substance produced by the liver that aids in the digestion and absorption of fats). These abnormalities lead to a build-up of bile acids (components of bile) in the mother's blood, resulting in symptoms such as severe skin itching.

What are the symptoms of ICP?The symptoms of ICP can range from mild to severe. Symptoms usually start in the second or third trimester of pregnancy. The most common symptoms include:

Skin itching: Itching often is most severe on the palms of the hands and soles of the feet, but many affected women itch all over their bodies. It often gets progressively worse and may interfere with sleep and daily activities.

Jaundice: This yellowing of the skin and whites of the eyes occurs in 10 to 20 percent of women with ICP (1). Jaundice is caused by a build-up of a chemical called bilirubin in the blood, resulting from the liver disorder and decreased bile flow.

A pregnant woman should call her health care provider if she has these symptoms.

How common is ICP? In the United States, ICP affects less than 1 percent of women (1).

What are the risks of ICP in pregnancy?ICP can be very uncomfortable for the pregnant woman. It also can hurt the baby. Up to 60 percent of women with ICP deliver prematurely (before 37 weeks of pregnancy) (2). Premature babies are at increased risk for health problems during the newborn period and for lasting disabilities and death. ICP also increases the risk for stillbirth, though the risk is small (1 to 2 percent) (1). It is important to diagnose and treat ICP to help prevent these potential problems.

How is ICP diagnosed? There are a number of skin disorders of pregnancy that can cause itching; most do not harm the mother or baby. Blood tests can tell if a woman's itching is due to ICP. These often include a blood test that measures various chemicals that show how well a woman's liver is functioning and the amount of bile acids in her blood.

How is ICP treated?
ICP often is treated with a medication called ursodeoxycholic acid (Actigall). This medication relieves skin itching, helps correct liver function abnormalities and may help prevent stillbirth.

The health care provider monitors the baby closely (with ultrasound and tests that measure heart rate) to see if the baby appears to be developing any difficulties, such as heart rate abnormalities, due to ICP. If the baby is having difficulties, the provider may recommend early delivery to help reduce the risk of stillbirth. The provider also may do a test called amniocentesis when the baby is at about 36 weeks gestation to see if the lungs are mature. If the baby's lungs are mature enough for the baby to breathe on his own, the provider may induce labor at 36 to 38 weeks to help prevent stillbirth (1).

What causes ICP?
The cause of ICP is not well understood. Pregnancy hormones and heredity appear to play a role. ICP appears to be more common in twin (or other multiple) pregnancies, possibly due to increased hormone levels (1). About half of women with ICP have a family history of related liver disorders (3).

Does ICP go away after giving birth?Symptoms of ICP generally clear up on their own by about 2 days after a woman gives birth. However, about 60 to 70 percent of affected women develop ICP again in another pregnancy (1).

HepatitisWhat is hepatitis?
Hepatitis is inflammation of the liver, usually caused by a virus. Several viruses can cause hepatitis. The most common are called hepatitis A, B and C.
What are the symptoms of hepatitis?
Symptoms of hepatitis can range from mild to severe. Some infected individuals have no symptoms at all. Common symptoms include:

Jaundice

Fatigue

Nausea and vomiting

Upper-abdominal discomfort

Low-grade fever

What is chronic hepatitis?
Some individuals who contract hepatitis B or hepatitis C do not clear the virus from their bodies, and the virus can remain in their systems for life. Individuals with a chronic hepatitis infection are at increased risk for severe liver disease or liver cancer. About 10 to 15 percent of individuals with hepatitis B, and at least 50 percent with hepatitis C, develop chronic infections (4). Individuals with hepatitis A do not develop chronic infections.

How is hepatitis treated?
There are no medications to treat acute (recently acquired) hepatitis infections. There are medications to treat chronic hepatitis B and C, but these usually are not recommended during pregnancy (5).

There are at least six antiviral drugs that can be used to treat hepatitis B. Little is known about the safety of these drugs in pregnancy. Some are suspected of increasing the risk of birth defects and miscarriage. Women should tell their health care provider before starting any of these drugs if they are planning pregnancy. Women who become pregnant while taking any of these drugs should call their provider. These drugs also are not recommended during breastfeeding.

Chronic hepatitis C can be treated with a combination of two antiviral drugs (ribavirin and pegylated interferon alfa-2a). These drugs are believed to contribute to birth defects and miscarriage. Women should avoid pregnancy while taking them and for six months after completing treatment. A woman should notify her provider immediately if she becomes pregnant while taking these drugs. They also should not be used during breastfeeding, or by male partners of pregnant women.

What are the risks of hepatitis in pregnancy?
Hepatitis A generally does not pose a risk to the baby when the mother contracts it during pregnancy. It is rarely passed from mother to baby during delivery (6).

Hepatitis B poses the greatest risk in pregnancy. Women who carry the virus in their system (acute or chronic infection) can pass it on to their babies during labor and delivery. In most cases, the risk is about 10 to 20 percent, though it can be higher if the woman has high levels of the virus in her body (4). Babies who are infected at birth usually develop chronic hepatitis B infection and face a high risk of serious liver disease and liver cancer as adults.

Hepatitis C is passed along to the baby during labor and delivery in only about 4 percent of cases (5).

How can hepatitis infection be prevented in babies?
The Centers for Disease Control and Prevention (CDC) recommends that all pregnant women be screened for hepatitis B with a blood test (5). If the blood test shows that a woman has acute or chronic hepatitis B, her baby should receive the hepatitis B vaccine and immune globulin (which contains hepatitis-fighting antibodies) within 12 hours of birth. This treatment prevents infection in more than 90 percent of babies at risk (5). The baby also should have two more doses of the vaccine in the first 6 months of life. The CDC also recommends that all babies be vaccinated against hepatitis B before leaving the hospital and at 1 to 2 months and 6 to 18 months (5).

There is currently no way to prevent a mother from passing hepatitis C to her baby.

How does a person get infected with a hepatitis virus?
Hepatitis A usually is spread through contaminated food and water. People who travel to developing countries are at increased risk. Hepatitis B and C occur after contact with blood or body fluids of an infected person. This may occur by sharing needles used to inject drugs or by having sex with an infected person (though hepatitis C is spread infrequently through sexual contact).

How can a pregnant woman protect herself from hepatitis? The best defense against hepatitis A and B is vaccination. Women who are planning to travel to a developing country should ask their provider if they should be vaccinated against hepatitis A. The hepatitis A vaccine has not been studied for safety during pregnancy, but it is not believed to pose a risk (6).

The hepatitis B vaccine is considered safe in pregnancy. Health care workers, public safety workers and others at high risk (such as women living with an infected partner) should consider getting the hepatitis B vaccine before or during pregnancy.

There is no vaccine against hepatitis C. Women also can help protect themselves from hepatitis B and C by following safe sex practices, avoiding illicit injected drugs, and not sharing personal care items that might have blood on them (razors, toothbrushes).

HELLP syndromeWhat is HELLP syndrome? HELLP syndrome is a dangerous pregnancy complication characterized by liver and blood abnormalities. HELLP stands for hemolysis (breakdown of red blood cells), elevated liver enzymes, and low platelet (blood cell fragments needed for blood clotting) count. It is a form of severe preeclampsia, a condition that can happen after the 20th week of pregnancy or right after pregnancy. It’s when a pregnant woman has high blood pressure and signs that some of her organs, like her kidneys and liver, may not be working properly. Some of these signs include having protein in the urine, changes in vision and severe headache. HELLP syndrome occurs in about 10 percent of pregnancies complicated by severe preeclampsia (7).

What are the symptoms of HELLP syndrome? Symptoms of HELLP syndrome usually occur in the third trimester of pregnancy, though they can begin earlier. Symptoms also may appear in the first 48 hours after delivery. A pregnant woman should contact her health care provider if she experiences these symptoms:

Pain in the stomach or upper-right abdomen

Nausea or vomiting

General malaise

Headache

How common is HELLP syndrome?
HELLP syndrome affects less than 1 percent of pregnant women (8).

What are the risks of HELLP syndrome? Unless treated promptly, HELLP syndrome can cause serious risks for mother and baby. In the mother, it can cause liver damage and, rarely, rupture; kidney failure; bleeding problems; stroke; and even death. When the mother develops serious complications, the baby's life also may be in danger. HELLP syndrome increases the risk for placental abruption (when the placenta peels away from the uterus before delivery), which can threaten the life of both mother and baby, as well as premature delivery.

How is HELLP syndrome diagnosed? HELLP syndrome is diagnosed with blood tests that look at levels of platelets and red blood cells and various chemicals that show how well a woman's liver is functioning.

How is HELLP syndrome treated?
Women with HELLP syndrome may be treated with medications to control blood pressure and prevent seizures, and sometimes with platelet transfusions. Women who develop HELLP syndrome almost always require prompt delivery to prevent serious complications. If a woman is at less than 34 weeks of pregnancy, delivery may be postponed for about 48 hours so that she can be treated with medications called corticosteroids (9). These medications help speed maturity of the fetal lungs and help prevent complications of prematurity. Some studies suggest that treating the pregnant woman for up to 48 hours with higher levels of corticosteroids than are used to speed fetal lung maturity may improve her symptoms (10).

What causes HELLP syndrome?
The cause of HELLP syndrome is not known.

Does HELLP syndrome go away after delivery?
In most cases, blood and liver abnormalities clear up within a few days after delivery. Women who have had HELLP syndrome usually have less than a 5 percent chance of it occurring again in another pregnancy (9). They do appear to have an increased risk for other pregnancy complications, such as preeclampsia, placental abruption and preterm delivery (9).

Acute fatty liver of pregnancyWhat is acute fatty liver of pregnancy?
Acute fatty liver of pregnancy is a rare, life-threatening complication of pregnancy. About 1 in 10,000 to 1 in 15,000 pregnant women are affected by this disorder, which is characterized by a build-up of fat in liver cells (11).

What are the symptoms of acute fatty liver of pregnancy? Symptoms of this disorder generally begin in the third trimester of pregnancy and may resemble those seen in HELLP syndrome. A pregnant woman should call her health care provider if she has any of these symptoms:

Persistent nausea and vomiting

Pain in the stomach or upper-right abdomen

General malaise

Jaundice

Headache

What are the risks of acute fatty liver of pregnancy?
Without prompt treatment, acute fatty liver of pregnancy can lead to coma, organ failure and death of mother and baby.

How is acute fatty liver of pregnancy diagnosed?
Acute fatty liver of pregnancy can be diagnosed with blood tests that measure a number of factors related to liver and kidney functions.

How is acute fatty liver of pregnancy treated?
The mother may require blood transfusions to stabilize her condition. The baby is delivered as soon as possible to prevent serious complications.

What causes acute fatty liver of pregnancy? The cause of this condition is not well understood. Genetics may play a role. A recent study found that 16 percent of women had this condition when their babies had certain inherited errors in body chemistry (fatty acid oxidation defects) (8). These disorders prevent an affected individual from properly processing certain fats. Babies with these disorders can develop life-threatening liver, heart and neuromuscular problems unless they are fed special low-fat foods. These findings suggest that all babies of women with acute fatty liver of pregnancy be tested for fatty acid oxidation defects so they can receive prompt treatment. (Many babies are routinely screened for these disorders as part of a panel of newborn screening tests. However, states vary in the newborn screening tests they require.)

Does acute fatty liver go away after pregnancy?
Most women start to improve within a few days of delivery and suffer no lasting harm from the condition. Women who carry a gene for a fatty acid oxidation defect (including women who have had an affected baby) have an increased risk of fatty liver occurring again in another pregnancy; the recurrence risk is unknown in other women (11).

Is the March of Dimes supporting research on liver diseases?
Yes. Several March of Dimes grantees are seeking to identify genes that may contribute to preeclampsia, a pregnancy-related form of high blood pressure that is related to HELLP syndrome. The goal of this research is to improve diagnosis and treatment of these disorders. Another recent grantee is seeking to develop treatment to stimulate liver regeneration in children with liver disease, including those with complications resulting from hepatitis.

Frequently Asked Questions

What is mononucleosis?

Mononucleosis (also called mono) is an infection usually caused by the Epstein-Barr virus (EBV). It’s sometimes caused by another virus called cytomegalovirus (CMV). EBV and CMV are part of the herpes virus family. Mono is most common in teenagers and young adults, but anyone can get it. Mono is called the “kissing disease” because it’s usually passed from one person to another through saliva. In addition to kissing, it can also be passed through sneezing, coughing or sharing pillows, drinks, straws, and toothbrushes.

You can have mono without having any symptoms. But even if you don’t get sick, you can still pass it to others. Symptoms can include:

If your symptoms don’t go away or get worse, tell your health care provider. He’ll most likely do a physical exam and test your blood to find out for sure if you have mono.

There’s no vaccine to prevent mono. There’s also no specific treatment. The best care is to take it easy and get as much rest as you can. It may take a few weeks before you fully recover.

Can Rh factor affect my baby?

The Rh factor may be a problem if mom is Rh-negative but dad is Rh-positive. If dad is Rh-negative, there is no risk.

If your baby gets her Rh-positive factor from dad, your body may believe that your baby's red blood cells are foreign elements attacking you. Your body may make antibodies to fight them. This is called sensitization.

If you're Rh-negative, you can get shots of Rh immune globulin (RhIg) to stop your body from attacking your baby. It's best to get these shots at 28 weeks of pregnancy and again within 72 hours of giving birth if a blood test shows that your baby is Rh-positive. You won't need anymore shots after giving birth if your baby is Rh-negative. You should also get a shot after certain pregnancy exams like an amniocentesis, a chorionic villus sampling or an external cephalic version (when your provider tries to turn a breech-position baby head down before labor). You'll also want to get the shot if you have a miscarriage, an ectopic pregnancy or suffer abdominal trauma.

I had a miscarriage. How long should I wait to try again?

Before getting pregnant again, it's important that you are ready both physically and emotionally. If you don't need tests or treatments to discover the cause of the miscarriage, it's usually OK for you to become pregnant after one normal menstrual cycle. However, it may take longer for you to feel emotionally ready to be pregnant again. Everyone responds differently to a miscarriage. Only you will know when you are ready to try to get pregnant again.

Are gallstones common during pregnancy?

Not common, but they do happen. Elevated hormones during pregnancy can cause the gallbladder to function more slowly, less efficiently. The gallbladder stores and releases bile, a substance produced in the liver. Bile helps digest fat. When bile sits in the gallbladder for too long, hard, solid nuggets called gallstones can form. The stones can block the flow of bile, causing indigestion and sometimes serious pain. Staying at a healthy weight during pregnancy can help lower your risk of gallstones. Exercise and eating foods that are low in fat and high in fiber, like veggies, fruits and whole grains, can help, too. Symptoms of gallstones include nausea, vomiting and intense, continuous abdominal pain. Treatment during pregnancy may include surgery to remove the gallbladder. Gallstones in the third trimester can be managed with a strict meal plan and pain medication, followed by surgery several weeks after delivery.

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